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Thyroidectomy – Total or PartialPatient Name:____________________________________What is the thyroid gland?The thyroid is a butterfly-shaped gland located in the front of the neck just below the voice box (Adam's apple). It is a small, soft gland that wraps around the front of the trachea (windpipe). The gland uses iodine to produce thyroid hormone, which has a key role in regulating such functions as energy level, heart rate, rate of metabolism, mental alertness, menstrual periods, and body temperature.When is thyroid surgery needed?Surgery of the thyroid gland may be recommended if there is: -a lump or tumor that may be cancerous -enlargement ("goiter") that is causing breathing, swallowing, or cosmetic problems -over activity (hyperthyroidism, thyrotoxicosis)How is thyroid surgery usually performed?Thyroid surgeries are generally performed in the hospital operating room under a general anesthetic. The surgery usually takes 1.5 hours to 3 hours and patients remain in the hospital overnight. An incision is made in the front of the neck along the collar line. Depending on the reason for the surgery, part or all of the thyroid gland is removed. Great care is taken not to injure the nearby voice nerves andcalcium glands. A small drain is placed and then usually removed within a few days. This is easy to care for at home. The early signs of low calcium include numbness, tightness, or tingling around the lips or within the face or hands. There may also be actual muscle spasms. You should tell your nurse (while an inpatient) or gothe emergency room or call the clinic (if already discharged) if these symptoms arise. You would have your calcium level checked, a few other electrolytes checked, possibly have an EKG, and possibly bestarted on calcium supplementation.What are the risks of surgery?Usually the surgery goes well and heals uneventfully. However, all Signature_______________________________surgeries have their risks and limitations. The risks noted below, unless otherwise stated, occur in about 5% or less of the patients.Bleeding, infection, unsightly scar, or temporary or permanent hoarseness. If one or both voice box nerves are injured, patients can still talk. However, the vocal quality will be altered.If just one side of the thyroid is removed, there is a risk to one of the voice box nerves. If this occurs and affects the voice, speech therapy may be needed. If that is needed and not helpful, a small surgicalprocedure may be needed to improve the voice. There is very little risk to the calcium glands if only one side of the thyroid is removed.If the entire thyroid is removed, patients may need to take calcium and Vitamin D every day for several months or years. If the entire thyroid is removed there is a very small risk that both of the voice boxnerves could be injured. If that occurs it can cause problems breathing that necessitate an emergency tracheotomy. This is very rare. Failure of surgery to improve symptoms thought to have come from pressure from an enlarged gland (such as difficulty breathing or difficulty swallowing.)What are the alternatives to surgery?The alternatives are not to have surgery and, instead, to continue to observe any nodules and/or to tolerate any difficulty breathing, swallowing problems, or cosmetic problems. In cases where there may be a tumor, delaying the surgery may lead to the need for more extensive surgery in the future and a worse prognosis.? Small areas of the lung can collapse, increasingthe risk of chest infection. This may needantibiotics and physiotherapy.? Increased risk in obese people of woundinfection, chest infection, heart and lungcomplications, and thrombosis.? Heart attack or stroke could occur due to thestrain on the heart.? Blood clot in the leg (DVT) causing pain andswelling. In rare cases part of the clot may breakoff and go to the lungs.Signature_______________________________? Death as a result of this procedure is possible.Specific risks:? Temporary or permanent loss of sensation to ear (pinna).? Intracranial complications are rare.Bleeding: It is possible, that you may have problems with bleeding during or after surgery. Should post-operative bleeding occur, it may require emergency treatment to drain accumulated blood or blood transfusion. Hospitalization may be required and hospital fees will be your (the patients) responsibility. Do not take any aspirin or anti-inflammatory medications for two weeks before surgery, or after surgery, as this contributes to a greater risk of bleeding. Hypertension (high blood pressure) that is not under good medical control may cause bleeding during or after surgery. Accumulations of blood under the skin may delay healing and cause scarring.Infection: Infection is unusual after this surgery. Should an infection occur, additional treatment including antibiotics or surgery may be necessary. The risk is increased in smokers and diabeticsScarring: You will have a scar. Although good wound healing after a surgical procedure is expected, abnormal scars may occur on the skin and deeper tissues. Scars may be unattractive and of different color than the surrounding skin. There is the possibility of visible marks from sutures. Additional treatments may be needed to treat scarring. Thick, wide or depressed scars or Keloid scars can occur and may require injections or more surgery or steroid shots, and these may not improve. If you have a history of Keloid or poor scars please notify your doctor. Damage to deeper structures: Deeper structures such as blood vessels, muscle, and particularly nerves may be damaged during the course of surgery. Injury to deeper structures may be temporary or permanent.Asymmetry: The human face is normally asymmetrical. There can be a variation from one side to the other in the results obtained.Signature_______________________________Surgical Anesthesia: Both local and general anesthesia involve risks. There is the possibility of complications, injury, and even death from all forms of surgical anesthesia or sedation. Allergic reactions may occur.Nerve Injury: Motor and sensory nerves may be injured during the procedure. Weakness or loss of movements may occur. Nerve injuries may cause temporary or permanent loss of facial movements and feeling. Such injuries may improve over time. Injury to sensory nerves of the face, neck, and ear regions may cause temporary or more rarely permanent numbness. Painful nerve scarring is very rare but can occur. Permanent numbness in this area is uncommon but can occur.Unsatisfactory Result: There is the possibility of a poor result. This would include risks such as unacceptable deformities, loss of movement, wound disruption, and loss of sensation. You may be disappointed with the results of surgery. You may need additional surgery. Surgery is not an exact science, and Dr. Ende will attempt to give you the best results possible however you may not receive the result you expect as individual results may vary. Complications can develop that are unexpected and are not even contemplated. The surgery may not improve you. Having a realistic expectation is important; if you have any concerns discuss them prior to surgery with Dr. Ende.Allergic Reactions: In rare cases, local allergies to tape, suture material, or topical preparations have been reported. Systemic reactions, which are more serious, may occur to drugs used during surgery and prescription medicines. Allergic reactions may require additional treatment.Delayed Healing: Wound disruption or delayed wound healing is possible. Some areas may not heal normally or may take a long time to heal. Some people may need extra healing time and may not be Signature_______________________________able to return to work or normal activities for a prolonged time. Areas of the skin may die. Frequent dressing changes or further surgery may be required to remove the non-healed tissue.Smokers: Smokers have a greater risk of complications and wound healing complications.Return to activities: Bruising, discomfort and pain are usually not severe. Some people may need extra healing time and may not be able to return to work or normal activities for a prolonged period.Additional Surgery Necessary: There are many conditions in addition to risk and potential surgical complications that may influence the long-term results. Even though risks and complications occur infrequently, the risks cited are the ones that are particularly associated with this procedure. Other complications and risks can occur but are even more uncommon. If complications occur additional surgery or other treatment may be necessary. The practice of medicine and surgery is not an exact science. Although good results are expected, there is no guarantee or warranty expressed or implied on the results that may be obtained. A touch up procedure is occasionally required. I understand that a touch up is the only recourse for dissatisfaction with my results. Follow-up Care: After care is an important part of you post surgical experience. It is your obligation to make sure that you keep all of your post surgical appointments and make sure that you promptly contact Dr. Ende in case of a medical emergency. I understand that if I seek medical care outside of Dr. Ende, Dr. Ende is not responsible for any expenses incurred.Photography: I also give my consent for photographs to be taken before, during, and after my operation. I further consent for such photographs to be used in connection with medical research, advertising, education and science. I understand that Dr. Ende will Signature_______________________________never publish my name in conjunction with any photographs. I understand that I have the option of crossing out this paragraph if I desire my photographs to be used for medical records only.I certify: I have read or had read to me the contents of this form; I understand the risks and alternatives involved in this procedure; I have had the opportunity to ask any questions which I had and all of my questions have been answered. I know that the practice of medicine and surgery is not an exact science, and, therefore, reputable and highly trained practitioners such as Dr. Ende can not and should not properly guarantee results.Refunds: There is a strict no refund policy for any treatments performed. I understand that the procedure does what it does, and that Dr. Ende puts his best effort and experience into every single patient. I understand that I am paying for Dr. Ende to perform this procedure as well as the cost of the material used and staff time/overhead and that I am not paying for any specific results implied or hoped for. While Dr. Ende takes a great deal of pride in his results and will do anything within his power to make me satisfied, additional procedures or products will have a cost associated with them. I have received a copy of this informed consent for my own records. I have had the opportunity to read this informed consent and my questions regarding the surgery, alternatives, risks, and expected outcomes have been answered. NOTE: You need to make a choice about receiving these health care items or services. Your insurance company may not pay for the item(s) or service(s) that are described below. Insurance companies only pay for covered items and services when insurance company rules are met. The fact that your insurance company may not pay for a particular item or service does not mean that you should not receive Signature_______________________________it. Right now, in your case, your insurance company may not pay for surgery Because: Your Deductible, Patient Responsibility Not covered with your contract, Out of network doctor or facility, Pre-Existing condition, Elective or cosmetic surgery.The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully. - Ask us to explain, if you don’t understand why your insurance company may not pay. YES, I want to receive these items or services. I understand that my insurance company will not decide whether to pay unless I receive these items or services. Please submit my claim to my insurance company and understand that you may bill me for items or services and that I may have to pay the bill while the insurance company is making the decision. If my insurance company does pay, you will refund to me any payments I made to you that are due to me. If my insurance company denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally either out of pocket or through any other insurance that I have. I understand I can appeal the insurance company decision. I further understand that if a touch up or further medical treatment is required, I will need to be seen by Kevin Ende MD at NJ Eye and Ear or Englewood Hospital. I understand that touch up, followup, or emergency visits will be free of charge in the office, but additional products and procedures will be at standard pricing. Any visits to Englewood Hospital for emergencies will be billed at Englewood Hospital’s standard rates or through your medical insurance provider. I certify that I will not leave slanderous/libelous reviews on any website. Speaking with Dr. Ende and allowing time to heal are necessary steps after every procedure, and I will not immediately jump to conclusions about my outcome before healing is complete. Slanderous statements unnecessarily scare future patients away from Signature_______________________________having procedures and realizing their dreams as well as having a negative financial impact on the practice. Due to HIPPA rules, Dr. Ende cannot reply to or combat any slanderous reviews online which will no doubt negatively impact his practice. I understand that Dr. Ende will use any resources available to him to combat libelous and slanderous statements including seeking financial compensation due to monetary damages through the legal system. I have been informed by Dr. Ende that patients need to be escorted home by a responsible adult and accompanied by an adult for at least 24 hours post-operatively. I understand that this is the policy of the practice. I acknowledge that I am responsible for ensuring that I have an escort to assist me in my transport home after surgery. I further acknowledge that should I fail to have an escort home, I am responsible for any staff salary overtime that this causes. I voluntarily release Dr. Ende from any liability regarding the above conditions if I knowingly choose to violate this policy. I assume all responsibility for my own well being following my surgical procedure if I knowingly go against medical advice.Facility Consent AddendumConsent for Treatment:I, the above named and undersigned patient, give my consent for care at and by the medical, nursing, and allied health professional staff of NJ Eye and Ear which may include routine diagnostic procedures and such medical treatment as Dr. Ende or his designees may find are needed. I acknowledge that no promises or guarantees have been made to me about the results of any examinations, treatments or procedures I may receive while at NJ Eye and Ear. Release of Medical Records:I authorize NJ Eye and Ear to release all or any part of my medical record to hospitals or medical service companies, insurance Signature_______________________________companies, workers compensation carriers, welfare funds or other organizations or agencies that may be concerned with the payment of costs related to my treatment and any other organization or agency to which the center is permitted to release such information under applicable laws. In the event that I am transferred to a hospital post-operatively, I authorize NJ Eye and Ear to obtain a copy of the hospital discharge summary.Financial Arrangements:I authorize and direct my insurer or payor to pay directly to NJ Eye and Ear any or all benefits, up to the amount of my bill, accruing to me in connection with my treatment. I agree that, in consideration of the services that were provided to me, I individually obligate myself to pay the amount promptly in accordance with the regular rates and terms of the facility. I understand, therefore, that to the extent permitted under applicable laws and contractual arrangements, I am financially responsible to the center for any amounts not covered by insurance. Furthermore, I understand that my insurer or payor may require certain health care services to be authorized before they are furnished to me. I individually obligate myself to pay the account of the center with respect to the services that I choose to receive notwithstanding that my health insurer or payor has refused to give preauthorization for all or any portion of my services. Pre-Certification:Your insurance company will be called to pre-certify your procedure. Please make sure that we have the correct insurance information. It is important to notify us if you have different plans for physician and hospital services. I understand that the reimbursement may be sent to me instead of NJ Eye and Ear. Upon receipt of the insurance payment, I will forward the check and the explanation of benefits to NJ Eye and Ear. In addition, I understand that my insurance plan may still hold me responsible for a deductable and/or coinsurance.Facility Charge:When your procedure is performed at NJ Eye and Ear, there will be a Signature_______________________________facility fee included in your overall fee. There is a charge for the use of NJ Eye and Ear’s procedure room included in your overall quote. Fees will vary according to the type of procedure that is being performed. Patient responsibility is dependent upon individual insurance plans. Collection Expenses: (excludes Medicaid and Medicare)Should my account with NJ Eye and Ear be referred to an attorney or outside agency for collection, I will pay all reasonable collection expenses (including attorney’s fees) associated with the collection effort. I acknowledge that all delinquent accounts will bear interest at the legal rate.Professional Fees:These are fees that are billed by Dr. Ende for his services in performing your procedure. These fees are within the range considered usual and customary for this area. Patient responsibility will vary according to each insurance plan. Anesthesia:The hospital or surgical facility outside of NJ Eye and Ear will have an anesthesiologist that will bill your insurance for their services. Discuss with the facility directly any questions that you have pertaining to billing.Biopsies:If a biopsy is required during the course of your procedure, a tissue sample will be sent to a laboratory to be analyzed by a pathologist. You may receive a separate bill from the pathologist. Dr. Ende may not anticipate the need to perform a biopsy with your procedure, but may need to make an intraoperative decision to due so without your verbal or written consent of that specific area. You hereby give general consent for an unexpected biopsy to be performed during the routine course of your procedure.Advanced Directive:It is Dr. Ende’s policy regardless of an advanced directive or Signature_______________________________instructions from a healthcare surrogate or power of attorney that if an adverse event occurs during treatment, Dr. Ende will initiate resuscitative or other stabilizing measures, and transfer you to an acute care hospital for further evaluation. Dr. Ende does not honor DNR orders at NJ Eye and Ear.Clothing and Valuables:I fully understand that the center is not responsible for any personal property brought in or retained in a storage area at any time. I fully understand that any valuables should be given to a family member or other responsible party for safekeeping. No reimbursement for lost or stolen items will occur. You may call the Englewood, NJ police if you choose to do so. Acknowledgement of driving risks:I have been informed by NJ Eye and Ear that I should not drive for at least 20 hours after completion of my procedure. A responsible adult, upon discharge from NJ Eye and Ear will accompany me home and stay with me over night. Signature_____________________________Date_________________________________ ................
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